Dr. Gullapalli Rao is an ophthalmologist and founder of the Hyderabad-based  L V Prasad Eye Institute (LVPEI). The Institute, which opened in 1986 and provides primary eye care to underserved populations using a cost-shifting model, one that’s become quite popular in public health in developing countries – take from those who can pay full price and help cover the costs of those who cannot pay.

What was your inspiration for founding LVPEI?

In 1974, I moved to the U.S. from India to train as an ophthalmologist, with the goal of returning to India to set up a center of excellence in ophthalmology along the lines of the best Academic centers in the U.S. While working as an academic ophthalmologist at the University of Rochester, N.Y., I began traveling back to India every few months to lay the groundwork and clear the bureaucratic hurdles for launching the Institute. To generate funding for the project, my friends and I formed the Indo-American Eye Care Society in 1984, which approached different groups in the U.S. for donations—my wife and I also donated all of our savings to this fund.

Then in 1986, we moved back to India, and our dream finally came true with the opening of LVPEI in the state of Andhra Pradesh. We understood that there were major barriers to care in Andhra Pradesh, particularly in the rural villages, such as high poverty levels and shortages of trained eye care professionals, which required a novel approach to the way eye care was delivered.

How is your model different?

Our solution was a community-based eye care model, which we coined the LVPEI Pyramid of Eye Care. This model addresses the shortage of primary eye care providers by recruiting and training local high school graduates to provide basic services, such as vision exams and diagnosis of eye conditions, at primary eye care centers that we developed near the villages.

For patients that need more advanced services, such as surgery, the primary eye care centers refer them to a secondary center, where they will be examined and treated by an ophthalmologist.

To fulfill our mission to provide care to everyone in need, regardless of their ability to pay, we also implemented a cross-subsidization business model, whereby revenue from paying patients covers deficits from nonpaying patients. As a result, more than half of the Institute’s 15 million patients have been treated for free.

How were you able to scale this model and were you concerned about sustainability?

Our business model is actually very sustainable. It centers around two core tenants that we’ve instilled throughout the Institute: a commitment to world-class eye care services and prudent fiscal management.

By focusing on high-quality clinical outcomes and patient satisfaction, we are able to continue attracting paying patients at a healthy rate.

With regards to fiscal prudence, our philosophy is fairly simple: ensure operating expenses are covered without depending on ‘soft funds’ like grants and donations; no loans or overdrafts; no pending payments; spend only what we earn.

Our employees understand that all of us have to take responsibility for managing resources efficiently, and they take that obligation very seriously.

Can you provide an overview on blindness and how your organization is working to address this issue on a global stage?

Ninety percent of the world’s blind live in developing nations.

This includes countries like India, with more than nine million blind people; China, with more than six million blind people; and other nations in Southeast Asia and Sub-Saharan Africa.

Historically, these countries have a higher prevalence of Vitamin A deficiency, River blindness and infections such as trachoma, the leading causes of preventable childhood blindness. In these countries, there is a cyclical relationship between blindness and poverty: the poor often cannot receive treatment for vision restoration, which restricts their employment opportunities and deepens their economic hardship.

In 1999, the World Health Organization and the International Agency for the Prevention of Blindness launched “Vision 2020,” an initiative focused on developing resources for vision care in developing nations.

As a member organization of Vision 2020, LVPEI has been helping eye hospitals in a number of countries to adopt its community-based eye care model.

We have introduced this model in more than 20 countries in the Western Pacific, South Asian and Sub Saharan African regions, providing training to specialists in all cadres, from ophthalmology and optometry to medical records and inventory management.

Do you feel that a community-based care model like the one at LVPEI could work in industrialized nations like the U.S.?

There is definitely an opportunity for this kind of model in industrialized nations. It’s important to note that in the U.S. there are underserved populations living in the vast rural regions, where access to ophthalmologists and optometrists is not proportionate with access in the cities.

The fact is that these professionals go through many years of formal education and often incur a lot of debt during the process. Thus, it shouldn’t be surprising that the annual net income for optometrists is above $130,000, according to the American Optometric Association.

But this level of compensation doesn’t fit the economic reality of many rural communities, where lower patient loads, coupled with higher poverty levels and lack of insurance, present significant barriers to fiscal sustainability for private optometry practices.

What is perhaps needed is a reorganization and segregation of services that matches needs with cost effective services.  This could be accomplished through some reorganization of eye care services at different levels, namely from primary to tertiary, and appropriately utilizing existing cadres of eye care professionals to match levels of care.

Matt Damon, co-founder of Water.org, held a press conference (a mock press conference) where he announced that he will not use the toilet.  Why?  To protest the fact that 2.5 billion people lack access to a toilet or basic sanitation.  So, he will be going on a “toilet strike.”

Damon pointed out that “780 Million people, that’s twice the population of the United States, lack access to clean water.” Thus, “in protest of this global tragedy, until this issue is resolved, until everyone has access to clean water and sanitation… I will not go to the bathroom,” he declared.

He goes on to explain that the toilet is the primary invention to save lives and yet today more people have cell phones than toilets.

Damon is working with a group of YouTube creators, including ShayCarl, EpicLloyd, WheezyWaiter, LivePrudeGirls, Smosh, Stan Lee, Lisa Schwartz, and John Elerick – all of them collaborating on Damon’s new “Strike with Me” campaign.

What are Gary White’s thoughts on this (humorous but poignant) strike?

“Matt’s strike announcement and the vlogger videos are designed to start an online conversation that can engage people across the digital landscape, and we hope people will share the video, and respond to it with their own thoughts…” said the founder and CEO of Water.org said.

And YouTube is one board.  Jessica Mason, YouTube for Good Manager, is in favor of technology for social impact:

“Water.org’s latest public awareness campaign shows how nonprofits can use video to raise
awareness about important issues.” -

There’s also a website site up to complement Damon’s plea, which individuals can engage in: http://strikewithme.org

by Ben Thurman

Careering down the serpentine road from Araku to Visakhapatnam, in the Eastern Ghats of Andhra Pradesh – one eye on an ailing girlfriend in the back seat of our battered Ambassador and one eye trying to appreciate the majestic scenery despite the severity of the situation – I began to ponder the difficulties of inhabiting such a remote location.

Indeed, Araku, less than a hundred miles from Visakhapatnam – the second largest city in Andhra Pradesh – is hardly that remote. Yet, it took us two hours, 1600 rupees and a semi-physical confrontation with a taxi driver to cross the mountain range to the nearest hospital. For the outlying tribal communities without the financial reserve that we enjoy, the journey would not be possible in the event of critical illness or childbirth.

Despite government initiatives to make vital healthcare more accessible to the rural poor – including the public-private partnership that established the ‘108’ Emergency Response Service – the problem remains disturbingly simple:

India does not have enough doctors, and those that it has are not willing to practise in the ‘interior’. Although India produces 45,000 medical graduates each year, the National Rural Health Mission reported in 2011 that 67% of rural positions are unfilled, with doctors wooed by the high salaries and urban postings of the private sector.

The Medical Council of India seeks to address the problem by making a six-month rural placement mandatory for all MBBS students, admitting that medical education is ‘at present … urban and big town-centric’. But with little incentive to practise in the rural hinterland after graduation, this seems to be little more than a stop-gap solution. India’s failure to provide affordable and accessible healthcare to its rural population – still an overwhelming majority at around 70% – requires a more innovative approach, one that has been developed by Amit Jain, President and CEO of e-Health Point.

Speaking at the Khemka Forum on Social Entrepreneurship in November last year, Amit explicated his ‘pioneering and futuristic social business model’ that in its short existence has impacted the lives of hundreds of thousands in underserved rural and peri-urban communities. e-Health Point operates a multifaceted approach comprising safe drinking water, telemedical video consultations, diagnostic tests and an affordable, licensed pharmacy on site.

With the goal of ‘democratising’ healthcare, e-Health Point has built a comprehensive model that provides quality and affordable services without discriminating against gender, caste or socio-economic status. Women and children – so often denied medical attention – constitute 60% of its clients; mobile consultation has reduced the travel costs that previously prevented people from seeking out medical consultation; pharmacies are managed to ensure that medication remains affordable; and, in doing this, hundreds of jobs have been generated.

Since 2009, e-Health Point has reportedly conducted over 30,000 consultations, processed some 35,000 prescriptions, and provided safe drinking water to half a million people. The potential for wide-scale change in healthcare for underserved communities has drawn organisations from USAID to Bloomberg to recognise Amit as one of the world’s most promising social entrepreneurs.

Yet at the Khemka conference, Amit emphasised the ‘pioneering’ nature of his business that combines technology with ‘bricks and mortar’. Issuing a caveat that technology alone cannot drive change, he highlighted the unique multi-service platform as the reason for e-Health Point’s success. Although advances in the application of mobile technology can affect positive social change, it has to be relevant and usable – not ‘technology for technology’s sake’.

His point is pertinent; one of the biggest pitfalls of m-Health is that patients are often unable to follow up mobile consultation with necessary medical attention: if a patient does not or cannot access primary care, the diagnosis is futile. Beyond technological solutions, there is an urgent need to change the entire health ecosystem. By combining the best of mobile technology with tangible infrastructure – on site pharmacies and safe drinking water facilities – e-Health Point has evolved a new approach to enable rural communities to access quality healthcare.

But it is a solution that is still developing. Despite its plaudits, there is little evidence to support the theory that m-Health has changed healthcare. Regardless of the increased occurrence of misdiagnosis in mobile consultation and misunderstanding in self-tracking devices,

mobile technology needs to be integrated with more touch points that influence health – pharmacies, clinics, hospitals and, crucially, doctors.

Despite claiming demonstrable ‘social impact’, it is unclear if pharmacies and safe drinking water represent sufficient infrastructure to change the whole health ecosystem and influence attitudes and practices towards healthcare. Whilst m-Health makes consultation more affordable and accessible, has it impacted the number of people seeking a medical opinion? And thereafter, how often are diagnoses followed up with necessary treatment?

The ‘global m-Health opportunity’ is a rapidly emerging market, estimated by McKinsey at $50 billion. Undeniably, there is huge potential to harness mobile technology to address operational challenges, distribute information and improve accessibility to consultation and diagnosis. However, it is still a nascent market; entrepreneurs are adapting and searching for the right model to affect widespread social change.

Whilst we should continue to make use of technology and develop mobile solutions for healthcare, rural India still demands increased infrastructure – more ‘bricks and mortar’ – for the nation’s poorest and most geographically marginalised to access the healthcare they require.

Ben Thurman is an IDEX Accelerator Fellow, a career launch-pad for aspiring social enterprise practitioners. Fellows undergo six months of leadership and business development training by working full-time with social enterprises in India.  IDEX Accelerator is supported by Gray Ghost Ventures, an Atlanta-based firm of impact investors.

(Photo Courtesy of Subject)

This Sunday, January 13, was the anniversary of India’s major polio milestone – marking two years without reporting a single case of polio.  We talk with Dr. Naveen Thacker, a pediatrician and polio expert, who has been part of the country’s leadership that’s been actively pushing for a polio-free India.

There has been significant press recently on the polio effort, ie. TIME magazine’s feature story on the fight against polio in Pakistan.  What would you advise the other polio-endemic nations, having seen success in India?

That ‘it’s possible’ and to keep going! We’re closer than ever before to eradicating polio globally. Experts once said that eradication in India was impossible but by proving them wrong, we’ve provided a blueprint for Afghanistan, Pakistan and Nigerian, the only three remaining endemic countries, to eradicate the disease.

India provides important lessons that can be replicated to ensure success. For example, in India we set up an Expert Advisory Group which looked holistically at the eradication programme and made recommendations as challenges arose. Critically, a strong partnership between the Government of India and a public and private sector partnership saw $2 billion being put towards polio eradication. This meant that a partnership that involved all levels of Government, the World Health Organisation, UNICEF, Rotary International, the U.S. Centers for Disease Control and Prevention and the Bill & Melinda Gates Foundation, was able to develop the largest and most successful vaccination drive in the world which meant every child in India was reached with the polio vaccine.

Advancements in technology meant we were able to quickly identify where polio outbreaks started from, which helped us control it quickly and reduce the number of children being affected by polio. Furthermore, a new vaccine (called Bivalent OPV) that was cheaper and effective against both Wild Poliovirus type 1 and 3  helped us over the final hurdles. Now we’ve reached zero cases, we have to remain vigilant to ensure that the disease does not return.

If we reach three years without a case of polio, India will officially be declared polio free by the World Health Organisation, however while there’s a single case of polio in the world we won’t be free of the disease. We’ve seen importation of polio before, in 2010 polio returned to China (imported from our common neighbour, Pakistan) and although plans are in place to both prevent and treat importation; vigilance is critical and will remain so for many years to come.

The polio structure developed over two years has already dramatically affected other health interventions. For example, as part of the Government’s efforts to reduce the incidence of measles, the illness now comes under the polio programme, highlighting the effectiveness of the programme. Furthermore, in large States like Bihar, routine immunisation has increased dramatically alongside polio coverage. Discussions are on going to use this vast network of NPSP and lab network  for surveillance of other Vaccine Preventable Diseases . More needs to be done but we’ve shown that we can reach every child in the country, repeatedly. Polio eradication isn’t a fluke and we must use it to ensure that we stop children dying of other preventable diseases. With 1.66 million children dying every year from preventable disease like pneumonia and diarrhoea  the highest child mortality in the world, now is the time to ensure that the polio success is scaled up.

Well, there’s a number of underlying causes that include everything from a lack of trained and fully supported health workers to parents refusing to take vaccines. We got past many of these problems by developing an army of vaccinators that were able to reach out to 172 million children each vaccination round but I agree that one of the underlying causes of polio was poor sanitation, hygiene and a lack of clean water.  This has an effect on multiple public health challenges and urgent action is indeed needed to solve these big problems.

However, it’s not about any one intervention being the silver bullet to solve all public health problems, it’s about looking at health holistically and developing a continuum of care that ensures that from the cradle to the grave, everyone has the right to access quality health information and services. To do that, a strong public health movement is needed to ensure that health rises up the political agenda, strong policies are put in place that are ultimately implemented and evaluated by the people at the local, State and national levels. It is promising to note that India is making significant progress by strengthening its health programmes and policies but this needs to be scaled up and accelerated.

While there are ad hoc campaigns to help polio patients, there has not been a national or regional system put into place to help those afflicted in polio.   Do you see that happening?  Will India move from vaccination to treatment?

Again we need to be doing everything. I don’t think anyone would deny that those affected by polio need good health care and support systems to help them cope with the disease. The right to health is enshrined in our constitution and we must develop a system to ensure that all people affected by the disease are suitably treated. Govt is well aware of this fact and there are systematic attempts with help of NGOs most importantly Rotary International for rehabilitation therapy for  these polio affected children

As well as making sure that people like Ruksa (the last polio case) are well looked after, we must also ensure that we vaccinate all children against polio and other diseases that are preventable. The threat of polio importation from endemic countries will remain in every country until polio is wiped out globally. Treatment versus prevention is the wrong paradigm; we need to be doing both.

Would does the victory against polio in India mean for you personally?

Achieving polio eradication is my life time mission and I have been working on polio since 1994. It is most satisfying to see that happening . As a young pediatrician, I remember seeing 55 cases of polio in just a  month   in my home state of Gujarat. I was shocked at the speed and devastation of the disease. When outbreaks happened, it was like dealing with a tidal wave that couldn’t be stopped. We fought back though and I initially created small booklets about the polio eradication . These were delivered to pediatricians nationwide and to Rotary clubs of polio-endemic countries. I personally wrote over 8,000 postcards every  year to pediatricians and Rotarians to support the Government’s Pulse Polio campaign and report cases of paralysis.

It was an honour to be invited to serve as a member of the India Expert Advisory Group and to work for over a decade with other experts and the Government to ensure that the polio programme was utilising national and international best practice to overcome major challenges.  I have also published a great deal of literature and delivered hundreds of speeches about polio so I feel like I’m heavily invested in India’s polio success.

In 2012, India’s polio eradication was the public health story of the year but we must build on this both nationally and globally. With 222 cases of polio so far recorded globally last year, down from 650 in 2001, we stand on the cusp of the biggest public health achievement of our generation. If we fail now, polio has shown through history that it is a resilient virus and it will come back. I’m proud of India’s achievement but this is not the time to celebrate. We must remain vigilant nationally and celebrate with the world when we finally reach the golden number for global cases of polio. Zero.

January 12th marked the third anniversary of the Haiti earthquake. The total cost of the disaster was between $8 billion and $14 billion, the Inter-American Development Bank estimates, with 200,000 to 250,000 deaths. The country is still struggling to rebuild and recovery efforts keep getting hit by new disasters: hurricanes and disease outbreaks.

ACDI/VOCA, an international development organization, works in Haiti’s Southeast Department, one of the country’s least food-secure areas. The USAID-funded program there works to build resilience by improving the health and nutrition of women and children, helping farmers increase productivity and developing an early warning system to better spot food-security crises.  

Artist Kerry Rodgers traveled to Belle Anse in the southeast and created drawings and text of program participants and staff that relay intimate portraits of the ongoing recovery. To date the ACDI/VOCA program has worked with 27,000 farmers introducing drought-tolerant and high-yield crop varieties and new planting techniques; and reached over 40,000 children and lactating women with its nutrition and health program. These are some of their stories:

Samahope, a new platform for public health campaigns, takes the fight for public health to the individual.

By Lindsay Hebert

The sixteen women on my computer screen need help. Natasha is three years old and requires $550 for a burn operation. Efreda was divorced by her husband because of her fistula condition; surgery will cost $1,000. When I refresh the page, a new tiling of faces appears.

The questions facing potential donors on Samahope.org are not new. Who is most deserving? Which cause is most affecting? How much do I contribute? But the answers seem to carry more weight when they apply not to a general fund, but to an actual person.

I asked Samahope’s program manager, Shivani Patel, for her advice on how to give. Launched in 2011, Samahope uses a crowdfunding model to raise money for surgical treatments in Zambia and Sierra Leone. Much like investing in a startup through Kiva or Kickstarter, donors can peruse the stories of women in need of operations and make contributions toward their surgeries.

“One way to choose would be to browse through and see what personal connection comes through. Or you could educate yourself on the different [medical] conditions and say, okay, what calls out to you as a donor and then go to the [patient’s] profile. There are different ways of leveraging the content to see what speaks to you. It depends on what lens you’re coming from,” Patel said.

The model is built on the premise that donors are more likely to give if they know the individual who will benefit. But some wonder about the ethical implications of placing such critical decisions in the hands of the public.

“This speaks to the potential of private charity, but also to its limitations.” said Dr. Howard Brody, director of the Institute for Medical Humanities for the University of Texas Medical Branch. “I can see the motive of people to have the reassurance [their money] is going to the right place. The unintended consequence is that it invites judgment of who is deserving and who is not. What about someone who has every bit a medical need but just doesn’t take a nice picture?”

For donors who prefer not to select a specific patient, a general giving fund is available on the site. This option was suggested during early feedback to alleviate donors’ potential decision-making stress. However, personal profiles bring in the majority of funding.

“What we found was that individual stories are more compelling,” Patel said. “Online, people are able to feel a sense of empathy to help a woman out.”

At this point, Samahope’s principal partner is West Africa Fistula Foundation, and women needing fistula repair surgery make up the majority of patients posted on the site. The Fistula Foundation estimates that more than 500,000 women worldwide are suffering from fistula, and that number increases by 30,000 to 50,000 women every year.

“The world’s capacity to treat women with fistula, however, lies at only about 20,000 women each year,” said Fistula Foundation CEO Kate Grant. “There is a significant patient backlog that keeps growing.”

While almost nonexistent in the developed world, this often-debilitating condition is common throughout Africa and Southeast Asia where prolonged labor during childbirth can lead to tears in the vaginal walls. This can cause incontinence and infection, stigmatizing those who suffer.

Despite the topic’s sensitivity, women who are unwilling to publicly post their condition are not eligible for direct funding through this model. But Patel says privacy concerns have come from academics and the development community, not from patients themselves.

“The reality is that many have been suffering from fistula for years and their lives have been halted. There is so much taboo in their communities about conditions that they have that are really no fault of their own. They say, ‘Yes, I want to tell my story.’”

But Brody wonders if patients really have the choice to participate if they have no other viable options for treatment.

“We see people having a bake sale for their neighbor with leukemia, and everyone in the community knows their business, knows that they’re suffering. At one level it’s a free choice, but really, honestly, is that socially the best way to do things? Or is there a better way to fund healthcare or give health insurance?”

Grant stands behind The Fistula Foundation’s more traditional fundraising methods. “Our preference is to share stories of a few patients – but for most of the women we help, we want to maintain their privacy. We find that [our donors] want to help women with this horrendous injury, and do not need to know about a specific patient’s condition in order to be moved to help.”

Samahope supports the most time-sensitive cases with targeted online promotion and with resources pooled in the general donation category. Patel says Samahope is committed to funding every surgery posted on the site.

“We try to tell each individual story with dignity, to focus on what the women are passionate about and what they are going to be able to do once they get back on track. But we try as much as possible not to shy away from tragedy. We don’t want to be scared to have that conversation and learn about that aspect of these women’s lives.”

Guest post by Nick Martin, CEO of TechChange, a social enterprise developing technology education for development and social impact. 

Four thousand attendees. Three days. Three challenges. One global network solution.

The 2012 mHealth Summit brought three main challenges to address in the next year to push forward with mobile phones for public health:

Beyond pilots; scale. The relative novelty of mhealth as a field has encouraged a “let a thousand flowers bloom” approach to see what sticks. But this culture of innovation has not kept pace with the fast development of the field as a whole, and thus the legacy of isolated small-scale pilots has continued instead of learning from what has been done before.   In Uganda alone there were 23 mHealth initiatives in 2008 and 2009 that did not scale up after the pilot phase. In India, there were over 30 mHealth initiatives in 2009 that did not go beyond the pilot phase. A number of recommendations were made to avoid “pilotisis” as it was deemed, including: improving monitoring and evaluation of these projects and basing all tech interventions in local contexts, needs and realities.

For more recommendations on how to scale mHealth projects effectively, check out this report published last year by the Advanced Development for Africa (ADA).

Interoperability first. The entire value of SMS and feature-based mHealth initiative is that the loss of functionality (say from using a smartphone) is more than counterbalanced by the size of the potential intervention — almost everyone has access to a dumbphone, even in the poorest areas that most benefit from mhealth initiatives. As such, standardization has the power to greatly enhance the efficiency of a health system.  In a number of countries, record keeping processes are so redundant and conflicting that the bureaucratic burden for users increases significantly.  (Watch a short animation about interoperability and tech standards). Government decision-makers have a significant role to play in aligning on standards and making health systems more efficient but funders and and other actors must also contribute meaningfully to this process.

Content and partners. The barriers to uptake of mHealth programming are rarely technical anymore. Too many affordable solutions exist for most needs and programs that have employed them effectively to imitate. What has been a barrier is distilling those lessons into effective training content and then forming partnerships to implement effectively. A number of new efforts are also underway to produce useful content for training and programmatic purposes. iHeed, an Irish Social Enterprise, believes that one million community health workers will be needed in coming years to provide quality health services to underserved populations. They are working on global health worker training by producing next-generation digital animated training content, and developing new blended training programs for health workers using mobile technology. mPowering Frontline Health Workers is another project aimed at providing training content and support to health workers.

Some of the organizations and projects I am most excited about include: Medic Mobile – a group that uses free and open source software to boost immunization rates by more than 20%, to contain disease outbreaks, and to make drug stock reporting 4x cheaper and 134x faster. Mwana – a project developed by UNICEF to use mobile phones to improve early infant diagnosis of HIV and post-natal follow-up and care. Mobile Alliance for Maternal Action (MAMA) a joint effort between USAID, UN foundation, Baby Center, and Johnson & Johnson which delivers vital health information to new and expectant mothers through mobile phones in a number of countries including Bangladesh, Ghana and South Africa.

The mHealth Summit was incredibly useful, but it’s not enough to meet once a year.
We need a global online community of practice. That’s why TechChange and the mHealth Alliance teamed up to build the first-ever online course on mHealth to bring people together, share best practices, and deepen their learning. Over the course of four weeks 100 participants from 25 countries engaged directly with experts via live video streaming, explored self-paced exercises and animations (See an example here), took part in software simulations and more. At the summit, we filmed a variety of experts sharing lessons learned to share with our course participants and the general public as immediately as if they had attended the summit (see interviews here).

(Photo Courtesy of TechChange features Nick Martin at the 2012 mHealth summit in Washington, DC)